Improved electrochemical performance and solid electrolyte interphase properties of electrolytes based on lithium bis(fluorosulfonyl)imide for high content silicon anodes.

Electrodes containing 60 wt% micron-sized silicon were investigated with electrolytes containing carbonate solvents and either LiPF6 or lithium bis(fluorosulfonyl)imide (LiFSI) salt. The electrodes showed improved performance, with respect to capacity, cycling stability, rate performance, electrode resistance and cycle life with the LiFSI salt, attributed to differences in the solid electrolyte interphase (SEI). Through impedance spectroscopy, cross sectional analysis using transmission electron microscopy (TEM) and focused ion beam (FIB) in combination with scanning electron microscopy (SEM), and electrode surface characterization by X-ray photoelectron spectroscopy (XPS), differences in electrode morphological changes, SEI composition and local distribution of SEI components were investigated. The SEI formed with LiFSI has a thin, inner, primarily inorganic layer, and an outer layer dominated by organic components. This SEI appeared more homogeneous and stable, more flexible and with a lower resistivity than the SEI formed in LiPF6 electrolyte. The SEI formed in the LiPF6 electrolyte appears to be less passivating and less flexible, with a higher resistance, and with higher capacitance values, indicative of a higher interfacial surface area. Cycling in LiPF6 electrolyte also resulted in incomplete lithiation of silicon particles, attributed to the inhomogeneous SEI formed. In contrast to LiFSI, where LiF was present in small grains in-between the silicon particles, clusters of LiF were observed around the carbon black for the LiPF6 electrolyte.

Implementation of the INTERGROWTH-21st Project in the United States.

The North American site in the INTERGROWTH-21(st) Project was North Seattle, Washington State, USA. The majority of the data were collected from within Seattle City, which has approximately 12 300 births per year. The sample for the Newborn Cross-Sectional Study (NCSS) was drawn from two hospitals (Swedish Medical Center and the University of Washington) covering almost 80% of deliveries within the target population. The Fetal Growth Longitudinal Study (FGLS) sample was recruited from several antenatal clinics serving the University of Washington Medical Center and Providence Everett Medical Center. Special activities to encourage participation and raise awareness of the studies included furnishing the recruitment sites with fliers designed by the Project Coordinating Unit, and presenting the studies to clinical staff to encourage providers to refer appropriate patients. One of the major challenges at this site was the low recruitment rate in the early phase of the FGLS because of the high rates of smoking, maternal age >35 years and body mass index >30 years. This was remedied by the inclusion of other ancillary clinics, as well as increased advertising among the general public.

Nationwide study of early outcomes after incisional hernia repair.

BACKGROUND: There are no nationwide studies on early outcomes after incisional hernia repair. METHODS: This study included all patients aged 18 years or more who had surgery for incisional hernia in Denmark between 1 January 2005 and 31 December 2006, and analysed clinical outcomes within 30 days of surgery. Patients having acute operations and those whose hernia repair was secondary to other procedures were excluded. RESULTS: Of a total of 2896 incisional hernia repairs (1872 open, 1024 laparoscopic), 2754 (95.1 per cent) were for primary hernia and 142 (4.9 per cent) for recurrence. The median hospital stay was 1 (range 0-88) day (open, 1 day; laparoscopic, 2 days); 10.0 per cent stayed for more than 6 days. Some 11.2 per cent of patients were readmitted (open, 10.1 per cent; laparoscopic, 13.1 per cent). Major complications were observed in 3.5 per cent (open, 2.8 per cent; laparoscopic, 4.8 per cent) with a total morbidity rate of 10.7 per cent (open, 10.1 per cent; laparoscopic, 11.8 per cent). The mortality rate was 0.4 per cent (open, 0.2 per cent; laparoscopic, 0.7 per cent). Morbidity and mortality were not related to surgical volume. CONCLUSION: Outcomes after incisional hernia repair seem unsatisfactory.

Clinical milestones predict symptom remission over 6-month and choice of treatment of patients with major depressive disorder (MDD).

BACKGROUND: It is uncertain as to what short-term outcomes predict long-term treatment compliance and outcomes in patients with MDD. AIMS: To determine what treatment milestones predict symptom remission with long-term treatment with antidepressant medication. METHOD: Pooled analysis of four randomised, double-blind, active comparator, 6-month trials in MDD. RESULTS: Patients received double-blind treatment with escitalopram (N=699) or a comparator (citalopram, duloxetine, or paroxetine) (N=699). Onset of effect at week 2 was correlated with response at week 8, and response at week 8 with completion of 6-month treatment. Week 8 response was associated with a greater probability of achieving later remission. Week 24 remission (MADRS>or=10) was significantly (p<0.01) higher for patients treated with escitalopram (70.7%) than for the pooled comparators (64.7%). Week 24 complete remission (MADRS

Improvement of quality of life in panic disorder with escitalopram, citalopram, or placebo.

BACKGROUND: It has been argued that measurement of outcome in panic disorder should not be limited to monitoring the number of panic attacks, but should include all domains that affect patient quality of life. METHODS: Data from a randomized prospective comparison of escitalopram, citalopram, and placebo in patients with DSM-IV panic disorder were analyzed with regard to measurements of impairment of quality of life. The subscales of the Panic and Agoraphobia Scale (P&A) (Panic Attacks, Agoraphobic Avoidance, Anticipatory Anxiety, Functional and Social Disability, and Worries about Health) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) were analyzed. RESULTS: Treatment with escitalopram was associated with significant improvement on all 5 subscales of the P&A. Citalopram was significantly different from placebo in 3 subscales. Escitalopram and citalopram were significantly better than placebo in improving quality of life (measured by the total score of the Q-LES-Q Scale). Escitalopram was superior to placebo on 12 of 16 items of the Q-LES-Q, while citalopram was superior on 7 items. CONCLUSION: The P&A scale was more robust than measurement of panic frequency in differentiating medication from placebo. Escitalopram treatment was associated with improvement on all assessed domains that impair quality of life in panic disorder. Measurement of clinical improvement should not be solely based on panic attack frequency, but should also include assessment of a broad range of domains that affect patient quality of life.

The influence of baseline severity on efficacy of escitalopram and citalopram in the treatment of major depressive disorder: an extended analysis.

OBJECTIVE: To determine the differences between escitalopram and citalopram in the treatment of patients with major depressive disorder across a range of baseline severity of depression using trend analysis. METHODS: Data from the three placebo-controlled studies comparing escitalopram to citalopram were analyzed. The pre-specified primary outcome variable was MADRS total score; secondary outcomes included Clinical Global Impression-Severity (CGI-S) and -Improvement (CGI-I) scores. All analyses were based on an intent-to-treat (ITT) population and all direct comparisons were done by ANCOVA adjusting for baseline value and centre. RESULTS: Analyses of the pooled data (N=1203) show that, while the difference between citalopram and placebo was approximately constant across the range of baseline severity, the difference between escitalopram and placebo (p=0.0010 for no trend) and between escitalopram and citalopram (p=0.0012 for no trend) became greater, the more severely depressed the patients were at baseline. A similar pattern was apparent with the CGI-S and CGI-I results. There was a significant superiority of escitalopram over citalopram in response rate (defined as > or = 50% decrease in MADRS total score), and this difference increased with increasing baseline severity. CONCLUSION: These trend analyses thus indicate that the superiority of escitalopram over citalopram is more apparent as the baseline severity of depression increases.

Effective dose of escitalopram in moderate versus severe DSM-IV major depression.

INTRODUCTION: Data from the three available placebo-controlled trials with fixed doses of escitalopram in the acute therapy of DSM-IV major depressive disorder (MDD) were pooled. The hypothesis tested was that escitalopram 10 mg/d might be an effective dose in moderate MDD, whereas escitalopram 20 mg/d might be needed in severe depression. METHODS: The Montgomery-Asberg Depression Scale with all 10 items was used at baseline to differentiate between moderate (score range 22 to 29) and severe (scores > or = 30) major depression. The MADRS (6) was selected as the primary efficacy parameter, using a standardised effect size of 0.40 as indicator of clinically significant response. RESULTS: After 8 weeks of therapy, escitalopram 10 mg was superior to placebo, with a standardised effect size above 0.40 for patients with moderate depression, but not for those with severe depression. In contrast, 20 mg escitalopram was superior to placebo, with a standardised effect size above 0.40 in severe depression, but not in moderate depression. The MADRS (6) showed response (standardised effect sizes above 0.40) for moderate depression after two weeks of treatment with 10 mg escitalopram and in severely depressed patients after 4 weeks with 20 mg escitalopram. CONCLUSION: Escitalopram 10 mg/d was the optimal dose for the treatment of moderate DSM-IV MDD, while escitalopram 20 mg/d was an effective dose in patients with moderate to severe depression.

The effect of escitalopram on sleep problems in depressed patients.

The results from three 8-week escitalopram studies in major depressive disorder are presented with respect to efficacy and the effect on sleep quality, both in the full population and the subpopulation of patients with sleep problems at baseline. Analysis of pooled data from these randomized, double-blind, placebo-controlled, studies in which citalopram was the active reference, showed a significant improvement for escitalopram-treated patients (n = 52.0) in the Montgomery-Asberg depression rating scale (MADRS) item 4 ('reduced sleep') scores at weeks 6 and 8 compared with placebo (n=398; p < 0.01) and at weeks 4, 6 and 8 (n = 403; p < 0.05) compared with citalopram.Escitalopram-treated patients with sleep problems (MADRS item 4 score > or = 4; n = 254) at baseline showed a statistically significant improvement in mean MADRS item 4 scores at weeks 4, 6 and 8 compared with patients treated with placebo (n = 191; p < 0.05) or citalopram (n = 193; p < 0.01). These patients also showed a statistically significant (p < 0.05) and clinically relevant improvement in MADRS total score after escitalopram treatment compared with citalopram at weeks 1, 4, 6 and 8 (observed cases) and endpoint (-2.45; last observation carried forward [LOCF]). Statistical significance in favour of escitalopram versus placebo treatment was found at all visits, including endpoint (-4.2; LOCF).Thus, these post-hoc analyses suggest that escitalopram has a significant beneficial effect compared with placebo or citalopram in reducing sleep disturbance in patients suffering from major depressive disorder. The effect of escitalopram in improving 'reduced sleep' scores was clearly seen in patients with more severe sleep disturbance at baseline. A further prospective study is needed to establish this useful clinical effect in insomniac depressives.

Citalopram dose-response revisited using an alternative psychometric approach to evaluate clinical effects of four fixed citalopram doses compared to placebo in patients with major depression.

RATIONALE: Among the many problems in interpreting dose-response studies with antidepressants are the psychometric problems in the identification of true antidepressive effect versus true adverse drug effect. OBJECTIVES: This study is a re-examination of a dose-response trial with citalopram in order to examine the explanatory ability of using strict psychometric dimensions to measure the wanted and unwanted drug effects of different doses compared to placebo. METHODS: The antidepressive response was measured after 2 and 6 weeks of therapy with the depression subscales of the HAM-D and on the Montgomery-Asberg Depression Scale (MADRS). The patient-reported Symptom Checklist (SCL) sub-scales for depression and anxiety were also examined. Subjective side-effects were measured on serotonin-specific items of the SCL. Effect size statistics were used to measure the antidepressive effect (an effect size of 0.30 equals a drug superiority over placebo of 15-20%). Side effects were statistically analysed using baseline-adjusted scores of the individual symptoms. RESULTS: The psychometric analysis of the outcome scales showed that the full HAM-D(17), the SCL-56 and the SCL side-effect subscale were multidimensional scales, while the HAM-D and MADRS subscales as well as the SCL-anxiety subscale were most homogeneous, indicating that their total scores are sufficient statistics. When the scales were used as well as the individual serotonin-specific SCL side-effect symptoms, the results showed that after 2 weeks of therapy a clinical response (effect side over 0.30) was only seen for the SCL-anxiety subscale in the citalopram doses of 40 mg and 60 mg daily. After 6 weeks of therapy response to even 10 mg and 20 mg was seen in the HAM-D and MADRS subscales and in the SCL-anxiety subscale, however, with lower effect sizes than found for 40 mg and 60 mg citalopram daily. The dose of 20 mg citalopram induced side-effects comparable with those seen for 40 mg and 60 mg, while 10 mg was not different from placebo. This was further confirmed by the fact that more patients dropped out on 20 mg than on 10 mg citalopram daily, due to adverse events. CONCLUSION: This psychometric re-examination of a citalopram dose-response trial has shown that the pure antidepressive or antianxiety effects can be observed after 6 weeks of therapy even in a dose of 10 mg daily. However, both 10 mg and 20 mg daily had lower effect sizes than 40 mg and 60 mg daily. At a dose level of 20 mg daily, side effects are more pronounced initially than at 10 mg daily; this should be taken into account clinically when evaluating the overall benefit of the drug. For a highly serotonin-specific drug such as citalopram, both wanted and unwanted effects are dose-related.

Use of fetal fibronectin in women at risk for preterm delivery.

Fetal fibronectin, a large molecular weight glycoprotein produced in the chorion, is expressed in cervical and vaginal secretions in women with disruption of the choriodecidual [table: see text] junction by labor or by inflammation. The presence of FFN in vaginal or cervical secretions before 35 weeks is a moderately good predictor of preterm delivery. The absence of FFN is a strong predictor that preterm delivery is unlikely within the next 7 to 14 days, with NPVs exceeding 99% in some studies. The predictive power of FFN is stronger at earlier gestation ages (24-28 wks) than it is later [table: see text] in pregnancy and is stronger for short-term prediction (7-14 d) than for predicting overall outcome (however, it remains statistically significant for predicting delivery < 37 wks). Although use of FFN in the clinical setting may require some changes to common protocols (e.g., performing sterile speculum examination before digital cervical examination), the use of FFN in patients with suspected preterm labor appears to have significant utility in reducing unnecessary interventions in women with symptoms suggestive of preterm labor. In women without symptoms, the use of FFN may be most beneficial in providing reassurance to some women thought to be at high-risk for preterm delivery because of past obstetric history. Screening women without symptoms at low-risk with FFN is not yet recommended because effective interventions are not demonstrated for patients found to be positive.

Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives.

OBJECTIVE: To determine whether pregnancy outcomes differ by provider group when alternative explanations are taken into account. METHODS: Pregnancy outcomes were compared for 710 women cared for by private obstetricians and 471 cared for by certified nurse-midwives. At intake, all women qualified for nurse-midwifery care. They were retained in their original group for analysis, even if they were later referred to physicians. Infant and maternal mortality, 30 clinical indicators, satisfaction with care, and monetary charges were studied. The study site's history and philosophy of honoring consumer choice of provider precluded random assignment, but multivariate analyses minimized the effects of multiple confounding factors. The statistical power was adequate for the study design. RESULTS: Significant differences (P < .05) between the obstetrician and nurse-midwife groups were found for seven clinically important outcomes: infant abrasions (7 versus 4%), infant remaining with mother for the entire hospital stay (15 versus 27%), third- or fourth-degree perineal laceration (23 versus 7%), number of complications (0.7 versus 0.4), satisfaction with care, average hospital charges ($5427 versus $4296), and average professional fee charges ($3425 versus $3237). When maternal risk, selection bias, and the medical intensiveness of care were controlled, the provider group did not continue to have an independent effect on infant abrasions, hemorrhage, and professional fee charges; when women's preferences were added, the difference in hospital charges disappeared. However, the provider group continued to have significant independent effects on the other four outcomes. Interaction effects were not significant. CONCLUSION: Although most outcomes were equally good, important differences between obstetrician and nurse-midwife care remained after multivariate analysis.

Fluconazole-induced congenital anomalies in three infants.

Fluconazole has been associated with various teratisms in animals, including craniofacial ossification defects, thin, wavy ribs, and renal pelvis defects. We describe three infants born to women who were receiving fluconazole through or beyond the first trimester of pregnancy. All of the infants had congenital anomalies; no other drug was implicated. Only one of the three infants survived. Their anomalies, similar to those observed in animal studies, were largely craniofacial, skeletal (i.e., thin, wavy ribs and ossification defects), and cardiac. One of these infants was previously reported as having Antley-Bixler syndrome; however, given the chronology described herein and the similarity of this infant to the others, we conclude that her deformities also represent the potent teratogenic effect of fluconazole.

A computer model of uterine contractions based on discrete contractile elements.

OBJECTIVE: To predict uterine contraction waveforms using a microcomputer-based model of uterine activity based on discrete contractile elements, varying the shape of the model, total number of cells, and pacemaker locations. METHODS: The model is a hollow ovoid composed of discrete contractile elements (cells) that propagate electrical impulses, generate tension, and have defined contracting and refractory periods. Each cell contacts eight surrounding cells and propagates impulses iteratively from cell to cell. Contraction pressure is the sum of the tension contributions by contracting cells. Sample contraction waveforms were generated based on various numbers of cells organized in ovoids with long:short axis ratios of 1:1, 3:2, and 2:1, with one or two pacemakers at varying positions. RESULTS: Contraction waveforms are altered by altering the shape of the matrix, but not by increasing the number of contractile elements. The vertical placement of the pacemaker has a dramatic effect on the shape and symmetry of contractions, including the development of patterns characteristic of "dysfunctional" uterine contractions. CONCLUSION: Abnormal uterine contraction patterns may result from pacemaker activity in unusual locations, such as mid-uterus. Further refinement of this computer model of uterine activity may contribute to a better understanding of the genesis of normal and abnormal intrauterine pressure waveforms and their relationship to the progress of labor.

Prediction of cervical cerclage outcome by endovaginal ultrasonography.

OBJECTIVE: We hypothesized that shortened upper cervical segment length, measured by endovaginal ultrasonography, identifies patients with cervical cerclage at greater risk of preterm delivery. STUDY DESIGN: A total of 121 endovaginal ultrasonographic examinations were performed on 32 patients after cervical cerclage. Ultrasonographic measurements included length of the closed cervical canal segments above and below the cerclage and dilatation of the internal cervical os (funneling) with and without fundal pressure. The risk of preterm delivery was tested by Fisher's exact test (two-tailed). RESULTS: Development of funneling of the internal os and shortening of the upper cervical segment length were the most predictive of outcome in patients with cervical cerclage. Twelve patients had shortening of the upper cervical segment (< or = 10 mm) before 30 weeks' gestation (mean 22.6 +/- 2.7 weeks), whereas 20 patients continued to have upper cervical segment measurements > 10 mm. A short upper cervical segment before 30 weeks' gestation was associated with a significantly higher risk of preterm delivery before 36 weeks (58% vs 10%, p = 0.006) and before 34 weeks (50% vs 5%, p = 0.006). CONCLUSION: Endovaginal ultrasonographic assessment of the cervix in patients with cervical cerclage is a useful adjunct for predicting outcome and for counseling the patient.

Are there differences in information given to private and public prenatal patients?

OBJECTIVES: In 1989 the United States Public Health Service Expert Panel on the Content of Prenatal Care reported that health education should become a more integral part of prenatal care. Key questions about providing this education have not been examined. Our study compared the type of information provided to women who sought prenatal care in a public clinic and to those who were seen in a private practice and the degree to which the patients were satisfied with the information they received. STUDY DESIGN: One hundred fifty-nine pregnant women (80 seen in a public clinic, 79 seen in a private practice) completed two questionnaires about 38 topics commonly cited as important during pregnancy. At the first prenatal visit, the women reported their level of interest in each of the topics. At 36 to 40 weeks' gestation the women completed a second questionnaire to assess whether information was provided for each topic and whether they had learned as much as desired. RESULTS: Overall, the women in the public sector received more information than did the women who were cared for privately. This was statistically significant at the p < 0.05 level for 25 of the 38 topics. Satisfaction with information learned was highly correlated with information received during prenatal care, but, surprisingly, it was not shown to be associated with the patient's interest level at the first visit. Fewer than 50% of private patients reported having received information about such important topics as acquired immunodeficiency syndrome, sexually transmitted diseases, preterm birth prevention, family planning, and family violence. CONCLUSIONS: The one-on-one approach to health education in pregnancy usually used in the private setting may not facilitate addressing many topics believed to be important components of contemporary prenatal care. Providers of private prenatal care should initiate discussion of prenatal health education topics rather than relying on patient interest in requesting information. Just as public prenatal care programs have devoted significant resources to more comprehensive prenatal education, the providers in the private sector must assure that pregnant women receive the same comprehensive information. In so doing, these providers can help promote an optimal outcome for their patients, their patients' unborn children, and the family unit.

What pregnant women want to know: a comparison of client and provider perceptions.

OBJECTIVE: To compare client and health-care provider perceptions concerning health topics. DESIGN: A survey conducted at the first prenatal visit asked women to indicate levels of interest in 38 topics. Providers answered the same survey, indicating perceptions of clients' interests. SETTING: A prenatal clinic and a private office, both in an inner city area. PARTICIPANTS: Two groups of prenatal clients (n = 135 private care and n = 250 public care) and their health-care providers (n = 32 nurses and physicians). RESULTS: Significant differences were found (p < .01 for four topics, p < .05 for six topics) between the clients' interests and the providers' perceptions. Women in private and public care differed significantly (p < .01) in their levels of interest. Interest was significantly affected by parity, but not maternal education. CONCLUSIONS: Nurses and other health professionals should be aware of the range of topics in which clients express interest. This study suggests that site of care and parity should be considered when developing prenatal health education.

Vaginal laceration following a jet-ski accident.

A 17-year-old woman riding as a passenger on a jet-ski fell behind the jet nozzle while jumping waves. A vaginal laceration with intra-abdominal extension occurred as a result of the accident. Hypogastric artery ligation controlled the hemorrhage and avoided more extensive surgery. The case represents an unusual injury from this type of watercraft and illustrates important points in the management of genital tract trauma.